Achilles Tendinopathy
Achilles tendinopathy is the most common overuse injury of the lower leg, affecting runners, basketball players, and middle-aged recreational athletes alike. Unlike an acute rupture, tendinopathy is a degenerative process: a chronic failure of the tendon to heal properly after repetitive microtrauma. The result is a tendon that is thickened, painful, and functionally weakened. Two anatomically and clinically distinct subtypes demand different treatments: midportion tendinopathy (2–6 cm above the calcaneal insertion) and insertional tendinopathy (at the bone-tendon junction). At Maryland Orthopedic Specialists, our approach is evidence-based and individualized, matching the treatment program to the specific diagnosis, activity level, and goals of each patient.
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What is achilles tendinopathy?
Achilles tendinopathy is a painful overuse condition of the Achilles tendon, which connects the calf muscles to the heel. Rather than true inflammation, it reflects failed healing with disorganized tendon fibers. Symptoms include pain, stiffness, and swelling at the back of the ankle that worsen with activity.
Achilles tendinopathy represents a failed healing response in the tendon rather than true inflammation. Histologically, the tissue shows disorganized collagen fibers, increased ground substance, and neovascularization (new blood vessel ingrowth). This pattern is termed tendinosis. The two subtypes differ significantly:
Midportion Tendinopathy
- Located 2–6 cm proximal to the calcaneal insertion, in the relatively avascular "watershed zone"
- Most common in runners and jumping athletes aged 35–55
- Associated with training load spikes, hard surfaces, and calf inflexibility/weakness
- Tendon is visibly and palpably thickened; the "painful arc sign" (tenderness that moves with the tendon on dorsiflexion) helps distinguish intratendinous from paratendinous pathology
- Royal London Hospital test: dorsiflexing the ankle reduces pain when the tendon is squeezed, indicating intratendinous pathology (positive in true tendinopathy); if pain does not change, paratendinopathy is more likely
Insertional Tendinopathy
- Located at the posterior calcaneal attachment, often with a Haglund deformity (prominent posterosuperior calcaneal bony prominence) and retrocalcaneal bursitis
- Pain with direct shoe counter pressure; worse at the start of activity ("warm-up pain")
- Eccentric exercises that load the tendon in plantarflexion below neutral (heel drops off a step) are contraindicated here, as they compress the already-irritated insertion
- Posterior heel calcification and enthesophyte formation are common on X-ray
Why the Distinction Matters
Midportion and insertional tendinopathy look superficially similar but respond to fundamentally different rehabilitation programs. Applying the wrong protocol (particularly aggressive eccentric heel drops in insertional disease) can worsen symptoms significantly.
Symptoms — do you recognize these?
- Midportion: Morning stiffness and pain in the tendon 2–6 cm above the heel; improves briefly with warm-up, worsens with extended activity; visible fusiform tendon swelling
- Insertional: Pain at the back of the heel at shoe counter level; worse with direct pressure, uphill running, and standing prolonged; posterior heel prominence (Haglund deformity)
- Both: Gradual onset over weeks to months; rarely a single traumatic event; pain with palpation, reduced calf strength endurance
Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations. Don't push through Achilles pain. Early treatment dramatically reduces recovery time.
How we diagnose it
Clinical examination is the primary diagnostic tool. Palpation identifies the location of maximal tenderness (midportion vs. insertion). The Royal London Hospital test, painful arc sign, and single-leg heel-rise endurance test (comparing to contralateral side) provide functional assessment.
Musculoskeletal ultrasound visualizes tendon thickness, hypoechoic degeneration zones, and neovascularization (Doppler signal) within the tendon. This is a marker of chronicity and pain source. Ultrasound is dynamic, low-cost, and performed in-office.
MRI offers superior soft-tissue detail, particularly for ruling out partial or full-thickness tears (important when symptoms suggest possible rupture), identifying retrocalcaneal bursitis, and evaluating adjacent structures.
Plain radiographs identify insertional calcification, Haglund deformity, and posterior calcaneal enthesophytes.
Treatment options
Achilles tendinopathy responds well to a structured loading program. Most patients improve significantly within 3 months.
Physical Therapy
Progressive tendon loading through eccentric (lowering-focused) heel exercises is the most evidence-based treatment; a physical therapist will tailor the program to whether you have mid-tendon or insertional disease, as the exercises differ. Starting slowly and building gradually is essential. The tendon needs load to heal, but too much too soon worsens symptoms.
Injections
PRP (platelet-rich plasma) injection is used for cases that haven't responded to therapy, with evidence supporting improved tendon healing. Corticosteroid injections are generally avoided as they can weaken the tendon.
Recovery & rehabilitation
- Exercise therapy: 12 weeks for meaningful improvement; full resolution may take 3–6 months
- ESWT: 3–5 sessions over 4–6 weeks; improvement continues for 3 months post-treatment
- Surgery (midportion): Full recovery 3–4 months; return to running 4–6 months
- Surgery (insertional): More prolonged recovery; running at 4–6 months is optimistic. Many patients require 6–9 months
Frequently Asked Questions
What's the difference between tendinopathy and tendinitis?
Can I keep running with Achilles tendinopathy?
Will I need surgery?
Is this the same as an Achilles rupture?
How long does it take for Achilles tendinopathy to get better with treatment?
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References
- Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998;26(3):360–366. doi:10.1177/03635465980260030301
- Beyer R, Kongsgaard M, Hougs Kjær B, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy. American Journal of Sports Medicine. 2015;43(7):1704–1711. doi:10.1177/0363546515584760
- Maffulli N, Longo UG, Kadakia A, Spiezia F. Achilles tendinopathy. Foot & Ankle Surgery. 2020;26(3):240–249. doi:10.1016/j.fas.2019.03.009
- Gatz M, Betsch M, Dirrichs T, et al. Extracorporeal shock wave therapy (ESWT) in the treatment of chronic Achilles tendinopathy: a prospective randomized controlled trial. Foot & Ankle International. 2020;41(2):139–148. doi:10.1177/1071100719890558
- OrthoInfo. AAOS. Achilles Tendinitis. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/achilles-tendinitis